Pain management; Nurses; Attitude of health personnel; Clinical competence; Hospitals, public; Developing Countries; Organizational support

Pain is one of the most frequent and distressing symptoms experienced by hospitalized patients, with studies reporting that up to 70–90% of patients suffer from moderate to severe pain during hospitalization [1,2]. Nurses, as the primary caregivers in clinical settings, are responsible for pain assessment, timely intervention, and continuous monitoring. However, despite their central role, research suggests that only 32% to 60% of nurses demonstrate adequate knowledge in pain management, and an even smaller proportion exhibit consistently positive attitudes toward pain relief strategies [3,4,5].

International studies have revealed that 40% of nurses fear opioid-related adverse effects such as respiratory depression or addiction, leading to reluctance in the administration of adequate doses, especially in elderly or postoperative patients [6,7]. Furthermore, over 40% of nurses reportedly underestimate patient-reported pain when objective signs (e.g., vital and facial expressions) are lacking [8,9]. In critical care and emergency settings, knowledge scores often drop even further due to workload pressure and clinical complexities, with some studies reporting only 50–76% competency in these environments [10].

In the Pakistani context, a recent cross-sectional study in Multan reported that while 67.3% of nurses had good knowledge about pain management, only 50.6% demonstrated favorable attitudes [11]. Similarly, inadequate training and a lack of formal education in pain assessment and management were among the most common barriers perceived by nurses caring for critically ill patients. [12]. Moreover, only 46.2% of nurses in a Lahore-based study reported using standardized pain assessment tools regularly in their practice [13]. These findings suggest a critical disconnect between the theoretical understanding and clinical application of pain management strategies, leading to persistent undertreatment of pain in public hospitals.

Educational interventions, especially those involving simulation or case-based training, have been shown to improve knowledge scores and significantly increase the likelihood of applying nonpharmacologic techniques or reassessing pain postintervention [14,15,16]. However, such structured programs remain limited in Pakistan’s public health system, where high patient volumes, inconsistent protocols, and a lack of continuing education prevail.

While prior research has relied primarily on descriptive or knowledge, attitudes, and practices (KAP)-based approaches, this study integrates the Knowledge and Attitudes Survey Regarding Pain (KASRP) with an additional dimension of perceived organizational support to reflect the broader institutional context influencing nurses’ competence. This framework enables a more comprehensive assessment of nurses’ pain management competence and allows exploration of how system-level support may facilitate or hinder effective clinical practice. Therefore, this study aims to assess nurses’ knowledge and attitudes toward pain management, examine their self-reported pain management behaviors, and evaluate how perceived organizational support contributes to their overall competence in a tertiary care hospital in Lahore, Pakistan.

2.1. Study design and duration

This was an exploratory study conducted over a period of two months, from December 2023 to February 2024.

2.2. Ethics approval

Ethical approval for this study was obtained from the Institutional Review & Research Advisory Board (IRRAB) and the Technical & Ethical Review Committee (TERC) of the National Health Research Complex and Sheikh Khalifa Bin Zayed Al-Nahyan Medical & Dental College, Lahore, Pakistan (No. TERC/SC/Internal/2023/513).

2.3. Sample size and sampling technique

A total of 120 registered nurses were recruited through convenience sampling from Mayo Hospital Lahore. The sample size was guided by Green’s formula for regression analysis (N ≥ 50 + 8 m), where m represents the number of predictors in the regression model [17]. This formula is used to estimate an adequate sample size to ensure sufficient statistical power in multiple regression analyses. In this study, with up to seven predictors, the formula yields N ≥ 50 + (8 × 7) = 106 participants. Given that the analysis included key predictors such as the KASRP score, perceived organizational support, self-reported practices, and relevant demographic variables, a sample of 120 participants was deemed adequate to meet the recommended threshold for robust multivariable analysis.

2.4. Study setting and population

This study was conducted at a public tertiary care hospital—Mayo Hospital Lahore—which is known for its high patient volume and wide range of clinical departments, including intensive care units (ICUs), emergency departments, medical and surgical wards, and outpatient units. The study population comprised registered nurses working in these departments who met the predefined inclusion and exclusion criteria.

2.5. Selection criteria

The participants eligible for inclusion were registered nurses working in a tertiary care hospital who were currently involved in clinical care within departments such as the ICU, emergency ward, inpatient ward, or outpatient unit and had completed at least six months of clinical experience following their internship. Nurses were excluded only if they were unavailable during the data collection period due to leave or reassignment. Participants who declined to take part, did not provide written informed consent, or submitted incomplete questionnaires were excluded from the study.

2.6. Measures and procedures

Data were collected via a structured, self-administered questionnaire developed from established instruments and tailored to the clinical context of nurses working in a public tertiary care hospital. The questionnaire was systematically divided into four thematic sections:

Section A covered demographic information, including age, sex, nursing qualifications (Diploma, Post-RN BSc, Generic BSc, or MSN and higher), years of clinical experience, current department or unit (e.g., ICU, emergency, ward, OPD), and whether the participant had received formal training in pain management.

Section B consisted of the complete 41-item KASRP, a validated tool developed by Ferrell and McCaffery [18]. This section assessed nurses’ knowledge and attitudes toward pain management through 22 true/false items, 14 multiple-choice questions, and two clinical case scenarios with multiple subquestions, including pain scale ratings and dosage decisions. The KASRP has been widely used in various clinical settings and has demonstrated acceptable reliability and construct validity in international contexts [19].

Section C included five items assessing perceived organizational support for pain management. These items evaluate the availability of protocols, supervisor support, access to tools, training opportunities, and adequate time for pain assessment and reassessment. Each item was rated on a 5-point Likert scale ranging from "strongly disagree" to "strongly agree." The concept of perceived organizational support is rooted in organizational psychology and has been previously validated as a predictor of professional performance and motivation [20].

Section D captured self-reported pain management behavior via five items that asked how frequently nurses engaged in practices such as using standardized pain scales, reassessing pain after interventions, documenting pain scores, using nonpharmacologic methods, and escalating unresolved pain to physicians. These items were rated on a 5-point scale from "never" to "always" [21].

2.7. Study measures

Scoring was carried out independently for each section of the questionnaire. For the KASRP (Section B), each correct response was awarded one point, resulting in a total score ranging from 0–41. Higher scores indicate greater knowledge and more positive attitudes toward pain management. No reverse scoring was necessary. For analytical purposes, KASRP scores were treated as a continuous variable and categorized into poor (< 50% correct), moderate (50–79% correct), and good (80–100% correct) knowledge and attitude levels [22].

Perceived organizational support (Section C) was measured using five-item scores. . Each item was rated on a 5-point Likert scale ranging from 1 (“strongly disagree”) to 5 (“strongly agree”), and the overall score was calculated as the median, with values between 1 and 5. Scores closer to 1 indicate low support, whereas scores closer to 5 indicate high support. All the items were positively framed, so reverse coding was not needed. Similarly, the self-reported practice score (Section D) was computed as the average of the five behavior items, where higher scores indicated more consistent application of pain management practices. These three scores—KASRP, organizational support, and self-reported practice—were analyzed both individually and collectively to explore how knowledge, workplace support, and behaviors relate to overall competence. This approach allowed for a broader understanding of the factors influencing effective pain management among nurses.

2.8. Data analysis

Data analysis was carried out using IBM SPSS Statistics (version 25.0). Descriptive analyses—comprising frequency distributions, means, standard deviations, medians, and interquartile ranges—were used to summarize demographic characteristics, KASRP results, levels of perceived organizational support, and reported pain management behaviors. To examine the associations between knowledge, support, and practice variables, Spearman’s correlation coefficients were calculated. Differences in KASRP and practice scores between binary groups were assessed using Mann–Whitney U test, where appropriate. Additionally, multiple linear regression was employed to determine significant predictors of knowledge outcomes, incorporating demographic factors and organizational support as explanatory variables. A two-tailed significance threshold of p < 0.05 was applied for all the statistical procedures.

Table 1 shows that the majority were female (90.0%), with a mean age of 39.5 ± 7.1 years. Most nurses held a diploma qualification (58.3%), followed by post-RN BSc (20.8%), generic BSc (13.3%), and MSN or higher degrees (7.5%). In terms of clinical experience, 39.2% of the nurses had 5–10 years of experience, 37.5% had less than 5 years, and smaller proportions had 11–20 years (18.3%) or more than 20 years (5.0%). Nurses worked across various departments: wards (43.3%), ICUs (20.8%), emergencies (20.0%), OPDs (10.8%), and other units (5.0%). Moreover, 35.8% reported having received prior training in pain management.

The average KASRP score among nurses was 27.00 (IQR = 18.00). According to the standard cutoff scores, 32.5% of the nurses reported poor knowledge, 45.0% reported moderate knowledge, and only 22.5% reported good knowledge. Perceived organizational support had a median score of 3.20 (IQR = 1.60), with a Cronbach’s alpha of 0.752, indicating acceptable internal consistency. The median self-reported pain management practice score was 3.60 (IQR = 1.15), with a Cronbach’s alpha of 0.705, also reflecting acceptable reliability.

Table 3 shows that there was a statistically significant positive correlation between KASRP scores and perceived organizational support for pain management (p = 0.007), suggesting that greater organizational support is associated with greater knowledge and attitudes toward pain management. However, no significant correlation was found between KASRP scores and self-reported pain management practices (p = 0.633).

Table 4 shows the results of the Mann–Whitney U test comparing male and female nurses’ KASRP and self-reported practice scores. While female nurses had slightly higher median KASRP scores (median = 27.00, IQR = 17.00) than male nurses did (median = 25.00, IQR = 17.75), the difference was not statistically significant (p = 0.324). Similarly, no significant sex difference was observed in pain management practice scores (p = 0.174), although female nurses again presented higher median values (median = 3.60, IQR = 1.20) than males did (median = 3.00, SD = 0.95).

Table 5 shows the results of a multiple linear regression analysis examining predictors of nurses' KASRP knowledge scores. The overall model was statistically significant, F(5, 114) = 3.150, p = 0.011, and accounted for 12.1% of the variance in knowledge scores (R² = 0.121). Among the predictors, perceived organizational support for pain management was the only statistically significant factor (B = 2.891, p = 0.003), indicating that greater perceived support is associated with greater knowledge and attitudes toward pain management. However, age, sex, nursing qualification, and years of experience were not significant predictors in this model.

The current study examined nurses’ knowledge and attitudes toward pain management, their self-reported practices, and the role of perceived organizational support. The findings revealed moderate overall KASRP scores, with nearly one-third of nurses falling into the “poor” category. A positive association was found between organizational support and knowledge scores, whereas practice scores did not significantly correlate with knowledge. Gender differences were not statistically significant, and organizational support emerged as a significant predictor of KASRP scores in the regression model.

These results align with those of national and international studies reporting similar deficits in nurses’ knowledge regarding pain. A recent study conducted across multiple hospitals in China reported that nurses scored an average of 40.3 ± 7.95 on the KASRP, with significant variation on the basis of training and department assignment [23]. In Pakistan, most nurses lack confidence in assessing and managing pain because of inadequate training and the absence of standardized pain protocols [24]. Comparable outcomes were observed among nurses in Cyprus, Saudi Arabia, and Egypt, where knowledge gaps were attributed to outdated curricula and a lack of structured continuing education [25,26,27].

Interestingly, in the current study, years of experience and academic qualifications were not statistically significant predictors of knowledge, which contrasts with findings from Jordan and Ireland, where higher academic credentials were associated with improved pain attitudes and practices [28]. This discrepancy may reflect context-specific limitations in Pakistan's clinical environment, where experiential learning is often unstructured and mentorship is lacking. The disconnect between formal education and actual practice has also been highlighted in Palestinian study, where clinical workload, time constraints, and hierarchical medical systems reduce opportunities for reflective practice and pain reassessment [29,30].

Perceived organizational support stood out as the only significant positive predictor of KASRP knowledge scores. This finding reinforces previous research from the U.S. and Europe suggesting that institutional investment—through training, supervision, and the availability of pain tools—directly enhances pain management competence [31,32,33]. In contrast, environments with weak leadership and ambiguous protocols often experience knowledge stagnation despite staff experience. A recent cross-sectional study in Ethiopia also showed that supportive environments, including regular feedback and interprofessional collaboration, led to better adherence to pain protocols [34].

Despite relatively high self-reported adherence to practices such as reassessment and documentation, there was no meaningful correlation between these behaviors and knowledge scores. This finding supports the notion that practice may be influenced by routine compliance or external factors (e.g., policies or peer behavior) rather than a deep understanding. Such discrepancies have been observed in Lebanon and Oman, where nurses reported following pain protocols but lacked clarity about pharmacologic options or assessment tools [35,36]. This suggests a need to reinforce the conceptual underpinnings of pain care alongside procedural compliance.

This study has several notable strengths, including the application of a validated tool (KASRP), the integration of perceived organizational support as an innovative variable, and the use of regression analysis to identify significant predictors. Nonetheless, it is important to acknowledge certain limitations. Since the research was conducted within a single tertiary care facility, the results may not be widely generalizable. Additionally, reliance on self-reported practices could have led to social desirability bias, and the exploratory design limits the ability to draw causal conclusions. Future research should explore longitudinal or multicenter approaches, incorporate observational methods to validate reported practices, and assess the impact of structured educational interventions—such as simulations or case-based learning—on sustained knowledge improvement.

This study reveals persistent gaps in nurses’ knowledge and attitudes toward pain management in a tertiary care setting in Pakistan. While nurses report adhering to practice standards, knowledge remains suboptimal. Notably, organizational support emerged as a key driver of improved knowledge, suggesting that systemic and institutional investments may yield significant improvements in patient pain outcomes. Interventions targeting workplace support, structured education, and leadership engagement should be prioritized.

Conceptualization, ZP, MA, NR, RM, and NB; methodology, ZP, MA, NR, RM, and NB; software, ZP, MA, and NR; validation, ZP, and MA; formal analysis, ZP; investigation, ZP, MA, NR, and RM; resources, ZP, MA, NR, and RM; data curation, ZP; writing—original draft preparation, ZP, MA, NR, and RM; writing—review and editing, ZP, and NB; visualization, MA, and NR; supervision, NB; project administration, ZP, and MA. All authors have read and agreed to the published version of the manuscript.

This research received no specific grant from the public, commercial, or not-for-profit funding agencies.

Ethical approval for this study was obtained from the Institutional Review & Research Advisory Board (IRRAB) and the Technical & Ethical Review Committee (TERC) of the National Health Research Complex and Sheikh Khalifa Bin Zayed Al-Nahyan Medical & Dental College, Lahore, Pakistan (No. TERC/SC/Internal/2023/513).

Not Applicable.

The data supporting this study's findings are available from the corresponding author, Zunaira Parveen, upon reasonable request.

None.

The authors declare no conflicts of interest.

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